Neurology & Pain Management Coding Alert

Question: Our group of neurologists evaluates a patient on day one. The following day the patient returns for a review of condition by the therapist. The therapist does not re-evaluate the patient. We usually bill an E/M code for the first day and prolonged services for the second, but I have recently been told that prolonged services must be performed on day one. What is proper coding for the second day?

Arizona Subscriber

Answer: According to CPT guidelines, prolonged services (99354-99357) are add-on codes used "to report the total duration of face-to-face time spent by a physician on a given date" [emphasis added]. Although time counted toward prolonged services need not be continuous, it must occur on the same date of service as the "base" E/M service to which the prolonged service codes are appended. In this case the therapist sees the patient on the day after the principal E/M service was provided, and therefore the prolonged service codes are not appropriate.

Correct coding for the second day depends on the exact circumstances of the visit. If the requirements of request, reason and response are met, the physical therapist may report the appropriate-level follow-up inpatient consult (99261-99263) for his or her services.

Note: For more information on consults (99241-99275), see Neurology Coding Alert, September 2001.

If the therapist provides services "incident-to" the primary physician, the follow-up visit must be billed as an established patient E/M service (99211-99215). Medicare defines incident-to services as services provided by a nonphysician practitioner (NPP), which are an integral part of the physician's personal professional services in the course of a diagnosis or treatment of an injury or illness. Services provided incident-to are reported using the appropriate CPT codes under the supervising physician's personal identification number and are reimbursed at 100 percent of the Physician Fee Schedule. Complete guidelines for billing incident-to are in section 2050 of the Medicare Carriers Manual.

If the therapist provides an evaluation under his or her own name, the correct code is 97001 (Physical therapy evaluation).

Except where otherwise noted, clinical and coding expertise for You Be the Coder and Reader Questions provided by Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine; and Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J.